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Abstract

Objective

To investigate cardiac rehabilitation utilisation and effectiveness, factors, needs and barriers associated with non-completion.

Design

We used the mixed-methods design with concurrent triangulation of a retrospective cohort and a qualitative study.

Setting

Economically disadvantaged areas in rural Australia.

Participants

Patients (≥18 years) referred to cardiac rehabilitation through a central referral system and living in rural areas of low socioeconomic status.

Main measures

A Cox survival model balanced by inverse probability weighting was used to assess the association between cardiac rehabilitation utilization and 12-month mortality/cardiovascular readmissions. Associations with non-completion were tested by logistic regression. Barriers and needs to cardiac rehabilitation completion were investigated through a thematic analysis of semi-structured interviews and focus groups (n = 28).

Results

Among 16,159 eligible separations, 44.3% were referred, and 11.2% completed cardiac rehabilitation. Completing programme (HR 0.65; 95%CI 0.57–0.74; p < 0.001) led to a lower risk of cardiovascular readmission/death. Living alone (OR 1.38; 95%CI 1.00–1.89; p = 0.048), having diabetes (OR 1.48; 95%CI 1.02–2.13; p = 0.037), or having depression (OR 1.54; 95%CI 1.14–2.08; p = 0.005), were associated with a higher risk of non-completion whereas enrolment in a telehealth programme was associated with a lower risk of non-completion (OR 0.26; 95%CI 0.18–0.38; p < 0.001). Themes related to logistic issues, social support, transition of care challenges, lack of care integration, and of person-centeredness emerged as barriers to completion.

Conclusions

Cardiac rehabilitation completion was low but effective in reducing mortality/cardiovascular readmissions. Understanding and addressing barriers and needs through mixed methods can help tailor cardiac rehabilitation programmes to vulnerable populations and improve completion and outcomes.

Keywords

Cardiovascular disease cardiac rehabilitation low socioeconomic status rural populations morbidity and mortality

Introduction

Low socioeconomic status is associated with poor cardiovascular outcomes.¹ Compared to high socioeconomic areas, the cardiovascular death rate in low socioeconomic areas is 1.3 times higher for males and 1.5 times higher for females.² Economic stability, neighbourhood-built environment, education and health care access, social and community relationships can be sources of chronic psychosocial stress. These stressors can activate biological responses that lead to autonomic dysfunction and chronic inflammation.³ All these processes contribute to an increased cardiovascular risk and explain why psychosocial risk factors (e.g. low socioeconomic status, low social support, depression, anxiety) tend to cluster together and co-occur with traditional risk factors (e.g. smoking, obesity, diabetes), ultimately resulting in increased cardiovascular events and mortality.³

These social determinants of health can be more prominent in rural areas, where 28% of the Australian population live, than in metropolitan areas.⁴ Socioeconomic status is typically lower in rural and remote areas relative to metropolitan areas. This, in combination with worse health services access in rural areas, may contribute to poorer cardiovascular outcomes reported for these areas. In Australia, people living in remote areas have a 1.4 times higher age-adjusted hospitalisation rate than those living in major cities.² For coronary heart disease, the leading cause of death, age-adjusted death rates are 1.3 times higher in remote areas than in Australia overall.²

Cardiac rehabilitation is a structured, multidisciplinary programme that includes exercise training and physical activity counselling, education, risk factor modification, diet counselling, and vocational and psychosocial support.⁵ Cardiac rehabilitation can improve functional capacity and the control of traditional cardiovascular risk factors which account for much of the association between low socioeconomic status and cardiovascular mortality.⁶ Cardiac rehabilitation is guideline-recommended^6,7 and effective in reducing mortality and hospital readmission at 12 months post-discharge.^8,9 However, globally, only 30–50% of eligible patients are referred, around 30% of the referred attend at least one session, and 10–30% complete the programme.¹⁰

Patients living in low-income areas are less likely to attend or complete cardiac rehabilitation after hospitalisation for a heart attack and to be informed about cardiac rehabilitation while in hospital.^11,12 We aimed to evaluate cardiac rehabilitation utilisation and effectiveness on clinical outcomes (readmissions and overall deaths) of patients with low socioeconomic status living in rural South Australia. Additionally, we sought to understand barriers to cardiac rehabilitation completion and the needs of patients with low socioeconomic status residing in rural areas.

Methods

Study design

This mixed-methods study had a concurrent triangulation and convergent parallel design.¹³ The quantitative analysis used a retrospective cohort design, including patients admitted for a cardiovascular event from 01 January 2016 to 30 June 2021 in rural South Australia. The qualitative study involved four semi-structured interviews and five focus groups with participants from low socioeconomic status areas in rural South Australia. Factors associated with non-completion and reasons for non-completion retrieved from the quantitative study were compared and related to the themes and sub-themes derived from the thematic analysis of the qualitative study¹³ (Figure 1).

Figure 1.

Mixed-methods study diagram.

Definitions

Low socioeconomic status was defined as an Index of Relative Socioeconomic Advantage and Disadvantage score within the two lowest deciles. The Index of Relative Socioeconomic Advantage and Disadvantage measures high and low income, degree of house mortgage, size of home, educational level, qualifications or none, employed as a professional, a manager, low skilled worker, machinery operator or laborer, high rent, number of cars or none, overcrowding, divorced, low rent, disability, unemployed, single parent family, no internet access and jobless parents from the Australian Census.¹⁴

Rural areas were defined as those outside metropolitan areas according to the Modified Monash Model which also considers distance to services to classify as rural (also named regional in Australia) according to its remoteness (inner regional, outer regional, remote, and very remote areas).⁴

Setting

All South Australian public hospitals and the 15 public cardiac rehabilitation programmes in rural areas, including the one delivered exclusively via telephone, were involved. All cardiac rehabilitation programmes receive referrals from metropolitan and regional hospitals via a central referral system. All programmes comprised the following core components: referral and access to services, clinical assessment and short-term monitoring, recovery and long-term maintenance, lifestyle/behavioral modification and medication adherence, and evaluation and quality improvement.¹⁵

Quantitative study

Participants

Eligible patients were adults (≥18 years); living in rural areas of South Australia with a low socioeconomic status; discharged alive from a hospital separation with a primary or secondary cardiac-related diagnostic code, with or without an interventional procedure, including acute coronary syndrome, heart failure, atrial fibrillation, acute myocardial infarction, percutaneous coronary intervention, coronary artery bypass graft, aortic or mitral valve replacements, automatic implantable cardioverter-defibrillator or permanent pacemaker.

A hospital separation was defined as from the beginning of admission to discharge. Separations across multiple hospitals, transfers, and readmissions within 24 hours were merged into one event. All the separations eligible to cardiac rehabilitation from the South Australian Department of Health Admitted Patient Care database between January 2016 and June 2021 (5.5 years) were included.

Variables/outcomes

The primary outcome was cardiac rehabilitation utilisation measured across three categories: did not receive cardiac rehabilitation (not referred or declined), commenced but did not complete cardiac rehabilitation, and completed cardiac rehabilitation. Referrals were defined by a health professional assessment and recorded in the South Australian cardiac rehabilitation programme database. Commencement (≥1 session) and completion as defined by a clinician were also characterised by a health professional involved in the patient care.

Secondary outcomes included a composite endpoint of all-cause mortality or admission for new/re-myocardial infarction, heart failure, atrial fibrillation, or stroke within 12 months of the index admission.

Data sources/measurements and linkage process.

The public hospital's database (South Australian Admitted Patient Care), the Emergency Department Data Collection, the South Australian Births, Death and Marriages, and the South Australian cardiac rehabilitation datasets were linked through deterministic linkages based on 11 identifying variables (client identification number, last name, first name, other names, date of birth, sex, date of death, weight at birth, street address, suburb, and postcode). Records not linked deterministically were analysed by probabilistic linkage and subsequently underwent clerical review if still unmatched.

The South Australian Cardiac Rehabilitation database (Country Access to Cardiac Health - CATCH database) captured dates of referrals, commencements, and completions; pre, post, 6- and 12-month cardiovascular risk factors, depression screening through Patient Health Questionnaire (PHQ)-2 and PHQ-9¹⁶; self-reported smoking and medication adherence; and exercise capacity. Additionally, it captures close-ended questions with a list of possible reasons for non-completion prompted by the clinicians to patients commencing but not completing cardiac rehabilitation.

Statistical methods

We used an inverse probability weighting model adjusted for age, gender, primary diagnosis, Charlson Comorbidity Index,¹⁷ prior heart failure, coronary disease, atrial fibrillation, revascularisation, malignancy, and socioeconomic disadvantage measured by the Index of Relative Socioeconomic Advantage and Disadvantage¹⁴ to account for the selection bias and unequal probabilities of cardiac rehabilitation completion. The balance of the inverse probability weighting model was tested by comparing the standardised difference (<10%) of the probabilities between the group that did not receive cardiac rehabilitation (was not referred or declined cardiac rehabilitation) versus those who commenced but did not complete and those who completed cardiac rehabilitation (Supplementary Table 1). As a prior diagnosis of dementia was not balanced across the groups in the weighted model (i.e. standardised difference ≥10%), we excluded patients with dementia (n = 135).

We compared patients’ demographics, clinical, and social characteristics across the cardiac rehabilitation utilisation categories through Kruskal–Wallis (for continuous variables described by median and interquartile range) and Chi-square tests (for categorical variables defined by proportions). The Shapiro–Wilk test was used to test the normality distribution of the data. Cardiac rehabilitation utilisation was reported as ratios, measured as proportions (%).

To assess the association of the secondary outcome (composite of cardiovascular readmission due to myocardial infarction, heart failure, atrial fibrillation, or stroke and all-cause mortality) and cardiac rehabilitation utilisation (three groups), we performed Cox proportional hazard models applied to the weighted population after testing for the proportional hazard assumption. The models were adjusted by age, gender, remoteness, primary cardiac diagnosis, referring hospital, and the Charlson Comorbidity Index.¹⁷ A p value of <0.05 was statistically significant, and Stata 15.0 was used for the analysis.¹⁸

For the sub-cohort of separations receiving cardiac rehabilitation, we investigated the association of non-completion (independent variable) with sociodemographic and clinical factors by adjusting binary logistic models for age, gender, remoteness (inner regional, outer regional, remote, and very remote), living alone, English as a second language, index separation characteristics pre or during the COVID-19 pandemic, the reason for referral (acute myocardial infarction, heart failure, atrial fibrillation, coronary artery bypass graft, percutaneous coronary intervention, valve procedures, implantable device procedures), Charlson Comorbidity Index, and history of comorbidities (diabetes, obesity, hypertension, depression), and the waiting time to commence cardiac rehabilitation from hospital separation.

Qualitative study

Qualitative data from 28 participants were collected through four semi-structured interviews and five focus groups, using the Experience Based Co-Design – A toolkit for Australia¹⁹ as a framework to engage with the participants through accessible, tangible ways (e.g. visual communication, scenarios, and personas). This approach helps patients with low literacy levels convey ideas and design better service experiences.¹⁹

Perceived barriers and needs from hospital discharge/referral to (non) attendance/completion of cardiac rehabilitation were explored through interviews and focus groups. The research questions and target groups in this phase were specific, and the sample size generated sufficient information for an in-depth analysis of the narratives.²⁰

The cardiac rehabilitation nurse recruited participants; the inclusion criteria were: being adults (≥18 years), referred to a cardiac rehabilitation programme in rural South Australia, and living in an area of low socioeconomic status. Cognitive impairment (Mini-mental short scale <20) was an exclusion criterion.

Interviews and focus group interviews’ audio recordings were transcribed verbatim by a professional transcription company. The de-identified transcripts were analysed using Braun and Clark inductive thematic analysis.²¹ Familiarisation with the topic was established through individual organic and subjective coding by AB and HD. Nodes were established independently and then examined collaboratively by AB, HD, CH, and MAPP after identifying recurrent themes to confirm final themes. Verbatim quotes were extracted to illustrate themes and sub-themes.

Reporting bias was mitigated by involving researchers from different disciplines and backgrounds (medicine, nursing, health economics, and public health) in the analysis. Additionally, these researchers were not involved in data collection. To reduce selection bias, we offered options for out-of-hours participation, and in-person or virtual/phone attendance. Participants were reimbursed for travel and participation time.

Ethics

The quantitative study received approval from the South Australian Department for Health and Wellbeing Human Research Ethics Committee (2021/HRE00270) for the use of linked data. A waiver of consent was granted to the project by the Department for Health and Wellbeing Ethics Committee. The qualitative study was approved by the Southern Adelaide Clinical Human Research Ethics Committee (LNR/22/SAC/71).

Results

Quantitative study

There were 16,159 separations eligible to this analysis after exclusion of patients with dementia (Figure 2). Participants’ median age was 71 (IQR 60-79) years, and 40.9% (n = 6,610) were female; acute myocardial infarction (n = 1773; 11.0%) and percutaneous coronary intervention (n=806; 4.9%) were the most frequent index admission single diagnosis and procedure, respectively. A referral was received by 7,159/16,159 (44.3%). Among the 7,159 who received a referral, 2,394 (33.4%) commenced cardiac rehabilitation, and among those commencing, 1,806 (75.4%) completed the programme. When assessed among the eligible, the completion rate was 11.2%. Characteristics of patients across the cardiac rehabilitation utilisation groups are displayed in Table 1.

Figure 2.

Quantitative study flow diagram.

Table 1.

Characteristics of the patients across groups of cardiac rehabilitation utilisation for the non-weighted population.

Characteristic	Overall population (16,159)	Did not receive cardiac rehabilitation (n = 13,765)	Commenced but did not complete cardiac rehabilitation (n = 588)	Completed cardiac rehabilitation (n = 1,806)	p value
Age	71 (60–79)	71 (60–80)	66 (57–73)	68 (59–74)	0.001
Female sex	6,610 (40.9)	5,879 (42.7)	190 (32.3)	541 (30.0)	<0.001
Charlson Score	1 (0–1)	1 (0–1)	1 (0–1)	1 (0–1)	0.286
Separation during the COVID pandemic	1,814 (11.2)	1,532 (11.1)	57 (9.7)	225 (12.5)	0.118
Diagnosis at index separation
Acute MI	1,773 (11.0)	1,210 (8.8)	124 (21.1)	439 (24.3)	<0.001
Congestive HF	1,501 (9.3)	1,373 (10.0)	37 (6.3)	91 (5.0)	<0.001
Arrhythmia	1,520 (9.4)	1,368 (10.0)	34 (5.8)	118 (6.5)	<0.001
Procedures at index separation
CABG	255 (1.6)	194 (1.4)	14 (2.4)	47 (1.6)	<0.001
PCI	806 (5.0)	516 (3.8)	56 (9.5)	234 (13.0)	<0.001
Valve procedures	508 (3.1)	453 (3.3)	12 (2.0)	43 (2.4)	0.034
Implantable devices	334 (2.1)	302 (2.2)	8 (1.4)	24 (1.3)	0.025
Additional cardiovascular diagnoses
Prior MI	1,568 (9.7)	1,035(7.5)	117 (19.9)	416 (23.0)	<0.001
Prior HF	619 (3.8)	552 (4.0)	21 (3.6)	46 (2.6)	0.009
Prior AF	23 (0.1)	21 (0.2)	0 (0.0)	2 (0.1)	0.587
Angina	533 (3.3)	425 (3.1)	20 (3.4)	88 (4.9)	<0.001
Peripheral vascular disease	54 (0.3)	48 (0.4)	2 (0.3)	4 (0.2)	0.678
Cerebrovascular disease	38 (0.2)	35 (0.3)	1 (0.2)	2 (0.1)	0.470
Hypertension	1,355 (8.4)	1,177 (8.6)	33 (5.6)	145 (8.0)	0.036
Other diagnoses
Diabetes	4,648 (28.8)	3,979 (28.9)	186 (31.6)	483 (26.7)	0.048
Dementia	135 (0.84)	135 (1.0)	0 (0.0)	0 (0.0)	<0.001
Cancer	630 (3.9)	589 (4.3)	12 (2.0)	29 (1.6)	<0.001
Chronic pulmonary disease	881 (5.5)	816 (5.9)	16 (2.7)	49 (2.7)	<0.001

MI: myocardial infarction; HF: heart failure; AF: atrial fibrillation; CABG: coronary artery bypass graft; PCI: percutaneous coronary intervention. * p values refer to comparisons across the groups that did not receive cardiac rehabilitation, commenced but did not complete, and completed cardiac rehabilitation and were tested by Kruskal–Wallis test for continuous variables and Chi-square for categorical variables.

The median time from discharge to commencement of a cardiac rehabilitation programme was 31 (IQR 18–51) days, and the median duration of the cardiac rehabilitation programme was 42 (IQR 30–61) days.

Living alone (OR 1.38; 95% CI 1.00–1.89; p = 0.048), having diabetes (OR 1.48; 95% CI 1.02–2.13; p = 0.037) or depression at baseline (OR 1.54; 95% CI 1.14–2.08; p = 0.005), and being enrolled in the telephone programme compared to a face-to-face programme (OR 0.26; 95% CI 0.18–0.38; p < 0.001) were associated with non-completion of cardiac rehabilitation.

Patient-related (not interested, n = 109; feeling unwell, n = 104; did not like or see value in the programme, n = 9), service-related (preferring to follow-up with the general practitioner, n = 46; cardiac rehabilitation programme time unsuitable, n = 8); and work/social circumstances-related (return to work, n = 42; transport/distance, n = 34; cost, n = 1) were reported as reasons for non-completion by 353 patients.

There were 4,066 composite events of all-cause death or admission for new/re-myocardial infarction, heart failure, atrial fibrillation or stroke) within the 12 months of follow-up after hospital discharge. After adjustment for sociodemographic and clinical factors, completing cardiac rehabilitation (HR 0.65; 95% CI 0.57–0.74; p < 0.001) was associated with a lower risk of cardiovascular readmission/death. Commencing but not completing cardiac rehabilitation was not significantly associated with the composite outcome (HR 0.94; 95% CI 0.78–1.13; p = 0.478) – Figure 3.

Figure 3.

Adjusted all-cause mortality/cardiovascular readmission rates within 12 months after the index hospitalisation.

Qualitative study

There were 28 participants in the qualitative study (24 participants from the five workshop focus group interviews and four patients’ individual interviews). Participants’ median age was 68 years (range 62–75), and six (21.4%) were women. All had English as a first language, and none were of Aboriginal and Torres Strait Islander heritage. Ten (35.7%) participants lived alone, and one participant reported having a carer. Two did not have access to the internet. Twelve (43%) were enrolled in a face-to-face programme and 16 (57%) in the telephone programme. Characteristics of the qualitative study participants are shown in Table 2.

Table 2.

Qualitative study of participants’ characteristics.

Participant	Marital status	Employment	Education
1	Married	Retired	Year 11 or below
2	Never married	Unemployed	Graduate Diploma/Certificate
3	Married	Working part time	Advanced Diploma
4	Married	Retired	Year 11 or below
5	Married	Working full time	Year 11 or below
6	Married	Retired	Certificate III/IV
7	Divorced	Working part time	Year 11 or below
8	Widowed	Working full time	Year 12
9	Divorced	Unemployed	Year 11 or below
10	Never married	Pensioner	Year 11 or below
11	Married	Pensioner	Advanced Diploma
12	Married	Retired	Advanced Diploma
13	Married	Working part time	Certificate III/IV
14	Divorced	Pensioner	Year 11 or below
15	Separated	Retired	Year 11 or below
16	Married	Pensioner	Year 11 or below
17	Married	Retired	Advanced Diploma
18	Never married	Unemployed	Certificate III/IV
19	Married	Retired	Year 11 or below
20	Married	Retired	Year 11 or below
21	Married	Retired	Year 11 or below
22	Married	Pensioner	Year 11 or below
23	Married	Working full time	Certificate III/IV
24	De Facto	Retired	Certificate III/IV
25	Married	Retired	Year 11 or below
26	Never married	Working full time	Certificate III/IV
27	Widowed	Unemployed	Certificate III/IV
28	Never married	Pensioner	Year 11 or below

Five overarching themes (logistic barriers, social support, transition of care, programme delivery, and care integration) and 19 sub-themes emerged from this study (Table 3).

Table 3.

Themes and sub-themes that emerged from the qualitative study.

Main themes	Sub-themes	Exemplar quotes
Logistic barriers	Distance and traveling	P21: “we're from the country (…) but people don't understand. It's a bit hard to be there by 8 [o’clock] in the morning when you're 3 hours away”.
	Costs	P3: “we had to pay for our own parking at the hospital”.
	Costs	P23: “no (costs associated with transportation) … Cause my rehab was over phone… Probably because I'm in the country, it may have been a problem if I had to travel out of my town somewhere else”.
	Need of flexible arrangements	P8: “It was a bit hard (…) I had to schedule it just before that, for 5:30 or 5:00 pm because I don't finish here until 8:30 at night (…)”
Social support	Dependency on family members	P7: “My daughter was really good and because I couldn't drive for six weeks…So, she was really good”.
	Support for those living alone	P2: “You've got all that, those people around you treating you and you know, doing things for you and then you're on your own. I found that once I got home because I live alone also. And you have all your friends around you and you're thinking, well they're going to be leaving in a minute. And I'm going to be here by myself. And I hadn't been by myself since I'd had it done. So it goes through your mind that can I cope?”
	Peer support	P15: “I think you just worry, and I don't think anything's going to really change that, not unless you're with people who have had heart attacks and explain it to you. That someone who's had a heart attack or maybe even two heart attacks and they just explain”.
Transition of care challenges	Lack of communication about cardiac rehabilitation	P5: “I saw that information myself, no one actually told me about it [cardiac rehabilitation]. I'm saying that my wife's friend told my wife that there was the cardiac course was cardiac rehab. I knew there was stuff there but I had no information on it. So I phoned here myself and I found that information and I went through all myself. The general practice never held me, the specialist never helped”.
	Uncertainty	P5: “….health wise, the first month was tough for me because, uh, you know, they said that the simple fact is that the stent there… and my doctor's boss said, you know, the simple fact is you may have had a stent, but it doesn't mean to say that you won't have another heart attack, Which sort of pulled me up a little bit. It made me think of my future with my wife…”
	Need of clear instructions delivered timely	P13: “I've just had a pacemaker and I don't know how to live with it at that point in time. So nobody tells you, you just live a normal life. Well I do now. I mean, don't even know I've got it. So just some more information in that first little while when you get out of hospital. It would be great feedback.”
	Feeling unsupported and losing trust in the system because waiting time to cardiac rehabilitation was long	P22: “When they didn't contact me for so long, I almost thought, oh, it doesn't matter. I'm not even going to worry about that and because they hadn't contacted me, so it would've been easy for me to have said no, I'm fine now.”
		P25: “Because it took so long. If they think you can handle yourself for that long…”
Programme delivery challenges	Need of active follow-up	P8: “I was told exactly what I should do and shouldn't do. I had the support from the cardiac nurse as well as the hospital if I needed it up here in XXX. I can't see anything more they could do apart from bit of nagging me”
Programme delivery challenges	Not getting enough support from clinicians	P21: “Well at least you can ask questions [in cardiac rehabilitation group sessions] … Yes, what I'm trying to think to say where when you go to a clinic or a doctor's surgery, you've only got a limited of time to ask certain questions, and then when you walk out the door, you are, “Oh, I forgot to ask about this or ask about that.” So at least on a conversation with this or in a conversation in a room of other people, you've got time to think of what you want to ask and find out about”.
	Other health problems prevented me from going to cardiac rehabilitation	P11: “I was. It was six months. I had the triple bypass. Then that failed a couple months after, so I had to go back in and spent five stents. Then they took my bottom of my lung out [due to lung cancer]. I was a bit wasted for six months. I'm still not right yet”.
	Need of personalised mental health support	P8: “I did suffer a bit of that stuff while I was talking to her [the nurse] that period of time. She helped me out quite a bit actually just on a conversation as well as what else to do or what else to contact. That did happen for probably about a month where I was in a bit of a dark space. She was quite very good and extremely good.”
	Need of tailored exercise training	P6: “They're trying to get me to do exercise which you'll spend for my heart and all that. I've tried to explain to tell them I can't, can't do it. Like I don't only have the heart problem. I've got blockages in both legs and it limits me to how much I can walk. I could only probably walk a hundred meters, walk 100 meters… My legs cramp up or if I stand too long they'll start cramping. If I squat down, well I might not get up. I believe people that can do it; it'll be a great thing to put to them”.
	Need of personalised education	P26: “The one piece of paper that they gave me up in XXX…Everybody that's had a stand for operations should have got the same piece of paper…there was a layout of what you could, what activities you could do within the first 8 weeks, 12 weeks or something (…) But (…) it was more of a laid out in stone. So you could not do this before this time, but you could not do this before this time and things like that. I'm young, I tried to follow that and it didn't work in any way, shape or form. So that form that is given to us when we have any major procedure… it needs to be a little bit more, I think it can be tailored a little bit. It's not individualized to the person”.
	Need to consider health literacy levels	P3: “So what I was saying was less medical terms, more layman's terms. You know I knew all the information, but when I tried to explain it to my children what had happened, it's more along the lines of being given the information, but in basic terms”.
Care is not integrated	Disconnection between the cardiac rehabilitation programme and the general practice	P12: “(…) the disconnect just seems to be there and they're not sharing information. That's really a bit of a gripe with me. It's my doctor should have had all the reports from [cardiac rehabilitation programme].”
	Lack of a person-centered, holistic approach	P17: “Nobody told me this [memory problems] was going to happen. I can't remember if I read it in the book. I must have met probably in the book, but there's so many thing that happens, which nobody told me about”.

We found convergence between the factors and reasons found in the quantitative analysis and the barriers and needs that emerged in the qualitative study (Table 4). However, for telehealth that was associated with lower chance of non-completion (i.e., patients receiving telehealth were more likely to complete cardiac rehabiliation), we found some divergence between the themes. Whereas the theme “logistic barriers” converged with the findings of telehealth increasing cardiac rehabilitation participation; in the qualitative study the emerging sub-themes “need of personalized mental health support”, “need of tailored exercise training”, and “(lack) peer support” were reported as barriers associated with telehealth.

Table 4.

Convergence of factors and reasons associated with non-completion and themes and sub-themes emerging from the qualitative study.

Factor/reason	Theme	Sub-theme	Exemplar quotes
Depression	Transition of care challenges	Feeling unsupported and losing trust in the system because waiting time to cardiac rehabilitation was long	P20: “Depression, big time. I've blamed that on no rehab because I think my expectation was too high. For real.”
Depression	Transition of care challenges		P19: “I expected rehab immediately after. I was looking forward to, and particularly because my partner started to talk about rehab. I mean XXX told me, she said, “Oh, the hospital called order to rehab.” I thought, “Great.” Then nothing happened. As I said before, I started rehab late. (…) I ended up with the same feeling. Not depressed, but it did depress me that I couldn't get anywhere. When I did rehab for two days or two hours, they say one hour, one week and one hour another week, or three hours of an hour”.
		Need of tailored mental health support	P14: “Everyone's different and if someone is depressed and all that, it might be better to see them face to face. So you've got a better idea of what the situation is.”
		Support for those living alone	P6: “She [the cardiac rehabilitation nurse] realized that I wasn't getting a lot of contact. So she went to my home so she could see face to face how things were and that really helped a lot just to know that you're on track because depression does creep in and the pain levels were pretty hard and you will think it's not nothing. As the other gentleman has said, you get up and you go for a walk and you do what you've got to do to push forward, but then you come home and you're fatigued and fall in a heap and start wondering if it's normal. Then there's no one to check up on that. You just, you really don't know what to do.”
Living alone	Transition of care challenges	Uncertainty	P2: “You've got all that, those people around you treating you and you know, doing things for you and then you're on your own. I found that one once I got home, because I live alone also. And you all your friends around you and you're thinking, well they're going to be leaving in a minute. And I'm going to be here by myself. And I hadn't been by myself since I'd had it done. So it goes through your mind that can I cope?”
	Social support	Dependency on family members	P15: “But would it be also better if a practitioner asked you right there and dead before you were discharged. Well do you live at home? Do you live alone honey? (…)Well they suggested I stayed with my son”
Telehealth	Logistic barriers	Distance and travel	P2: “I think that's one of the things that cause the Royal Flying Doctors take you to the hospital in XXX [metropolitan area]. But they don't bring you back home. And I think that's one of the big faults in the system is the fact that you've got to find your own way home.”
	Logistic barriers	Flexible arrangements	P14: “And then there's also the fact that get time off work… I didn't have any of those problems because I was just a phone call “.
	Logistic barriers	Costs	P23: “no [costs associated with transportation] … Cause my rehab was over phone… Probably cause I'm in the country, it may have been a problem if I had to travel out of my town somewhere else.”
	Programme delivery challenges	*Need of personalised mental health support	P14: “Everyone's different and if someone is depressed and all that, it might be better to see them face to face. So you've got a better idea of what the situation is, but it's a bit harder to tell what a person's like over the phone but I was all right”.
	Programme delivery challenges	*Need of tailored exercise training	P6: “I think the telephone is good in the beginning after that face to face. … She [nurse]'s said, “You've got to walk half an hour,” such and such. If you are in my case, you can’t go to the hospital where they got the machine you can go on there and somebody is telling you what to do. That [telephone-based cardiac rehabilitation] is not enough. To me, that's not enough.”
	Social support	*Peer support	P17: “Whether there are people going through the same thing, maybe there are, whereas, when you're in the country, you just get on the phone and do what you got to do and yeah. There was no really social.”
Not interested	Transition of care challenges	Lack of communication about cardiac rehabilitation	P21: “…if someone had told me when I left the hospital that a person, a counsellor, or someone was going to ring me on a monthly basis, fair enough, I would've been expecting it, but nothing was said about that. And when the lady did ring, it was quite out of the blue and I was quite surprised to hear and find out what was going on, yes… No one explained to me early that that was going to happen”.
	Transition of care challenges	Need of clear instructions delivered timely	P14: “I sort of don't go to the doctor because I've had no need to go to a doctor. But I suppose I'd just go to the doctor and get a blood test and find out what my cholesterol that is. I guess when you have to do it off your own back, you don't seem to find time to do that, but if there's an agenda set, then I guess it'll get done… If I had like a programme like say, on the first of every month, I'd go and get a blood test and it was set and I would do it. But if I had to organize myself, I probably wouldn't worry about it “.
	Programme delivery challenges	Need of active follow-up	P21: “I didn't even know which I found out now. The lady's name was XXX. When she rang me about a month after the procedure. I was surprised what was going on here. But then she rang monthly for about four months, and then she let it go and was supposed to ring in six months’ time, which was supposed to be yesterday, but no, it didn't eventuate, so we won't worry about that”.
	Programme delivery challenges	Need to consider health literacy levels	P18: “There's so many acronyms and not enough layman's terms. This is the biggest issue.”
	Programme delivery challenges	Need to consider health literacy levels	P5: “That list [checklist of medications] is a great idea. But in that same process, again, this is another one of those simple terms. Right. Instead of medical terms, simple terms. … sometimes you just sit there and it's a bunch of numbers and it's not quite sure…”
	Transition of care challenges	Feeling unsupported and losing trust in the system because waiting time to cardiac rehabilitation was long	P22: “When they didn't contact me for so long, I almost thought, oh, it doesn't matter. I'm not even going to worry about that and because they hadn't contacted me, so it would've been easy for me to have said no, I'm fine now.
	Transition of care challenges		P25: “Because it took so long. If they think you can handle yourself for that long…”
Preferring to follow-up with the general practitioner	Care is not integrated	Disconnection between the cardiac rehabilitation programme and the general practice	P28: “I find my experience is that there's a disconnect between the cardiologist, the general practice community health. They don't seem to talk to each other. And it's not, I don't think it's a cohesive thing that is happening.”
Preferring to follow-up with the general practitioner	Care is not integrated		P15: “Cause my own doctor how they get to do the, before you do the exercising, the doctor's got to sign a form. She rings me up and says, what's this form about? (…) Nobody else, the hospital hasn't contacted her with any information. No, there seems to be just a total disconnect. And I went and had a down a call or I had to go for the echocardiogram and get a hold of monitor but on me. And I've got to go back down there and see the cardiologist. But there seems to be a big disconnect between my general practice, who's my main carer, medical and even myself and them.”
		Not getting enough support from clinicians	P14: “the heart specialist that coming over and he, he spoke to me for about, don't get this wrong. Five minutes. See you later.”

Discussion

This study showed low utilisation rates of cardiac rehabilitation by people of low socioeconomic status living in rural Australia. On the other hand, completing the programme was associated with a 35% reduction in the risk of death or hospital admission; attending the programme without completing it was not associated with a risk reduction in this population living in rural low socioeconomic areas. The main reasons for non-completion were lack of interest, being unwell and preferring follow-up within primary care only. Living alone and having diabetes or depression increased the risk of non-completion, but being enrolled in a telehealth programme decreased the risk of not completing. There was convergence of the factors/reasons with the themes emerging from the qualitative study except for needs around telehealth-delivered cardiac rehabilitation.

Lemstra et al. (2013) showed lower cardiac rehabilitation attendance and completion rates (6.4% versus 14.8% in our study and 37.9% versus 75.4%, respectively) and higher waiting times (123 days versus 31 days) among people living in low-income neighbourhoods in Canada after hospitalisation for ischemic heart disease or revascularisation procedure.¹¹ Conversely, completion rates among those who started cardiac rehabilitation were higher in a Danish study than in ours (97.7% versus 75.4%, respectively).²² Their model of care included an extra number of cardiac rehabilitation sessions, telephone follow-up, and involvement of general practices and patient associations in the maintenance phase for their socially vulnerable group.

Living alone was associated with a higher risk of not completing cardiac rehabilitation by our quantitative study and reported as a barrier to cardiac rehabilitation participation in our qualitative study. Living alone was related to feelings of being unsupported which coincides with findings that it is a proxy of low social support and worse clinical outcomes.²³

Long waiting times were reported as a contributing factor to feeling depressed, and being unsupported leads to a decreased interest in cardiac rehabilitation. Likewise, lack of or unclear communication about cardiac rehabilitation during the hospital stay and transition of care period were referred as sources of low interest in cardiac rehabilitation which relates to the evidence that physician endorsement²⁴ and enrolment by a nurse or allied health professional increase cardiac rehabilitation participation.¹⁰

Another factor that could be leading to disinterest in cardiac rehabilitation is clinician communication occurring at a health literacy level that was not appropriate as reported in our qualitative study. As health literacy may influence both patient satisfaction and self-management of risk factors,²⁵ programmes should consider evaluating health literacy and addressing the patient's needs. This may involve helping patients with (i) finding and (ii) appraising health information, (iii) navigating the health care system, and (iv) engaging with health care providers.²⁶

The perception that the general practitioner was not involved with cardiac rehabilitation may reduce the programme value to patients leading to low participation. Ensuring that intake and discharge transition records are shared with the primary care provider can improve integration of care. However, <50% of the general practices receive an intake transition record from the cardiac rehabilitation programme.²⁷

Cardiac rehabilitation delivered via telehealth was independently associated with cardiac rehabilitation completion, which can be explained by telehealth increasing access to care by minimising logistic barriers such as distance and travelling, costs and scheduling flexibility.²⁸ However, participants highlighted that mental health support, exercise training, and peer support were weaknesses of the telehealth program. Tailoring these components to the needs of special subgroups rather than a one-size fits all approach may help to improve the quality of telehealth delivery, increase completion and clinical and patient-reported outcomes. For example, programme tailoring to women's needs has been associated with gains in health-related quality of life during cardiac rehabilitation.²⁹ Moreover, offering alternative forms of exercise, such as yoga and Tai Chi Chuan, could facilitate personalisation and lead to improvements in cardiac rehabilitation adherence and participation particularly among women.³⁰

As limitations of our study, we acknowledge that its observational design limits generalisability and that, despite the use of the inverse probability weighting and extensive model adjustment, selection bias and residual confounding may still have occurred despite adjustment for clinical and sociodemographic factors. Additionally, it is likely that women, people with English as a second language and Aboriginal and Torres Strait Islander peoples were underrepresented in the qualitative study which may have impacted the emergence of the themes.

As a message to clinical practice, we would highlight that, as programme completion was key to reduce the risk of hospitalisation and death among people of low socioeconomic status living in rural areas, it would be advisable to concentrate on cardiac rehabilitation quality improvement initiatives around issues that may lead to improved completion. These may include: (i) identifying patients who live alone and providing them with social support; (ii) reducing waiting time; (iii) communicating the benefits of cardiac rehabilitation timely and at an appropriate health literacy level; (iv) integrating cardiac rehabilitation with primary care; (iv) offering telehealth as an option of cardiac rehabilitation delivery and designing telehealth models that enable tailored mental health support, exercise training, and peer support; (v) personalising mental health support and exercise programme.

In conclusion, our findings reinforce that completion of cardiac rehabilitation is paramount to the achievement of clinical benefits in patients with low socioeconomic status living in rural areas. However, completion remains low. Addressing barriers and needs related to logistics, social support particularly to those living alone, transition of care, care integration, and lack of person-centredness of the programmes especially through telehealth-enabled models of care may increase the interest and value of patients with socioeconomic disadvantaged leading to improved participation and clinical outcomes.

Clinical messages

Programme completion reduces the risk of hospitalisation and death among people of low socioeconomic status living in rural areas.

Focus cardiac rehabilitation initiatives on:

(ι) identifying and supporting patients living alone

(ii) reducing waiting time

(ιιι) offering telehealth as an option of programme delivery, personalising, and improving mental health support, exercise, and peer support.

Supplemental Material

sj-docx-1-cre-10.1177_02692155241236998 - Supplemental material for Clinical effectiveness of cardiac rehabilitation and barriers to completion in patients of low socioeconomic status in rural areas: A mixed-methods study

Supplemental material, sj-docx-1-cre-10.1177_02692155241236998 for Clinical effectiveness of cardiac rehabilitation and barriers to completion in patients of low socioeconomic status in rural areas: A mixed-methods study by Alline Beleigoli, Hila Ariela Dafny, Maria Alejandra Pinero de Plaza, Claire Hutchinson, Tania Marin, Joyce S. Ramos, Orathai Suebkinorn, Lemlem G. Gebremichael, Norma B. Bulamu, Wendy Keech, Marie Ludlow, Jeroen Hendriks, Vincent Versace and Robyn A. Clark in Clinical Rehabilitation

Footnotes

Acknowledgements

We acknowledge the contribution of the cardiac rehabilitation patients, South Australian public health cardiac rehabilitation service providers, and the Heads of Unit across the Department of Health Local Health Networks, and the SA/NT Datalink consortium for providing the data linkage and the Integrated Cardiovascular Clinical Network, Rural Support Service, South Australiaa especially Dr Philip Tideman (in memoriam) and Rosy Tirimacco.

Author Contributions

The study was conceived and designed by AB and RC. AB, MAPP, CH, RC, WK, ML, PT, and JH secured funds for the study. AB analysed the quantitative data. AB and HD analysed the qualitative data with input from MAPP and CH. JSR, OS, and TM collected the qualitative data. The first draft of the paper was written by AB with input from all co-authors. All authors read and approved the final manuscript.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

This study was supported by a Flinders Foundation Health Seeding Grant and by the Country Heart Attack Prevention (CHAP) project, a peer-reviewed National Health and Medical Research Council (NHMRC Partnership Grant GNT1169893). VV is funded by the Rural Health Multidisciplinary Training (RHMT) programme (Australian Government Department of Health and Aged Care).

Author's note

Robyn A. Clark, Department of Health, Southern Adelaide Local Health Network, South Australia, Australia.

Data Availability Statement

The data underlying this article cannot be shared publicly due to SA Health policy for data linkage privacy. The data will be shared on reasonable request to the corresponding author.

ORCID iDs

Alline Beleigoli

Maria Alejandra Pinero de Plaza

Supplemental material

Supplemental material for this article is available online.

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